Summary

There is level 1a evidence (from three RCTs; Stohrer et al. 1999; Stohrer et al. 2007; Stohrer et al. 2013) supports the use of propiverine in the treatment of detrusor hyperreflexia resulting in significantly improved bladder capacity, with one of these trials showing equivalent results to oxybutinin but fewer side effects, notably dry mouth.

There is level 1 evidence (from a single RCT; Stohrer et al. 2013) that demonstrated superiority for continence and tolerability when propiverine extended-release is compared to immediate release formulations.

There is level 1 evidence (from a single RCT Ethans et al. 2004) that supports the use of tolterodine versus placebo to significantly increase intermittent catheterization volumes and decrease incontinence in neurogenic detrusor overactivity.

There is level 2 evidence (from a prospective controlled trial; Ethans et al. 2004) that tolterodine and oxybutynin are equally efficacious in SCI patients with neurogenic detrusor overactivity except that tolterodine results in less dry mouth.

There is level 4 evidence (from pre-post studies; O’Leary et al. 2003; Kennelly et al. 2009) that supports the potential benefits of controlled-release oxybutynin as well as a transdermal system for oxybutinin administration, the latter with a reduced side effect profile.

There is level 4 evidence (from a prospective controlled trial; Amend et al. 2008) that suggests benefits such as reduced incontinence and increased bladder capacity from combination treatments of two of oxybutinin, trospium chloride or tolterodine, even in patients with unsatisfactory outcomes following a trial with one of these medications.

There is level 1a evidence (from two RCTs; Stohrer et al. 1991; Madersbacher et al. 1995) that support the use of trospium chloride to increase bladder capacity and compliance, and decrease bladder pressure with very few side effects in SCI individuals with neurogenic bladder.

There is level 1b evidence (from one RCT; Wyndaele & Van Kerrebroeck 1995) that demonstrates that cisapride is not clearly effective in the treatment of hyperreflexic bladders in individuals with SCI.

There is level 1a evidence (from several RCTs) that supports the use of onabotulinum toxin A injections into the detrusor muscle to provide targeted treatment for neurogenic detrusor overactivity and urge incontinence resistant to high-dose oral anticholinergic treatments with intermittent self-catheterization in SCI; numerous level 3 and 4 studies confirm the efficacy and safety.

There is level 4 evidence (from one post test study; Dasgupta et al. 1998) that intravesical capsaicin instillation in bladders of individuals with SCI does not increase the rate of common bladder cancers after 5 years of use.

There is level 2 evidence (from one RCT; George et al. 2007) advocating for propantheline and oxybutynin intravesical instillation as adjuvant therapy, with propantheline being superior in more cystometric parameters, for neuropathic bladder managed with clean intermittent catheterization.

There is level 4 evidence (from a pre-post study; George et al. 2007) that supports the use of capsaicin intravesical instillation to improve leak volume and frequency. However, this study also revealed that capsaicin intravesical instillation worsened residual volume and cystometric capacity, and can induce hyperreflexia in patients with SCI and neuropathic bladder.

There is level 1b evidence (from one RCT; Steers et al. 1992) that intrathecal baclofen may be beneficial for bladder function improvement in individuals with SCI when oral pharmacological interventions are insufficient.

There is level 4 evidence (from one case series; Chartier-Kastler et al. 2000a) that the use of intrathecal clonidine improves detrusor overactivity in individuals with SCI when a combination of oral treatment and sterile intermittent catheterization is insufficient.

There is level 4 evidence (from oone pre-post and one case series study; Perkash 1995; Chancellor et al. 1993a) that supports terazosin as an alternative treatment for bladder neck dysfunction in SCI individuals provided that side effects and drug tolerance are monitored.

There is level 4 evidence (from one case series study; Al-Ali et al. 1999) that indicates some potential for phenoxybenzamine as an adjunct treatment for neurogenic bladder following SCI, when tapping or crede is insufficient to achieve residual urine volume of<100mL.

There is level 4 evidence (from one case series study; Linsenmeyer et al. 2002) that 6 months of alpha-1 blocker therapy may improve upper tract stasis secondary to SCI in men by decreasing the duration of involuntary bladder contractions.

There is level 1 evidence (from one RCT and several controlled and uncontrolled trials; DeSeze et al. 2002) that botulinum toxin injected into the external urinary sphincter may be effective in improving outcomes associated with bladder emptying in persons with neurogenic bladder due to SCI.

There is level 4 evidence (from one case series study; Weld & Dmochowski 2000) that prolonged indwelling catheterization, whether suprapubic or urethral, may result in a higher long-term rate of urological and renal complications than intermittent catheterization, condom catheterization or triggered spontaneous voiding.

There is level 4 evidence (from two case series studies; Yavuzer et al. 2000; Green 2004) that those who use intermittent catheterization at discharge from rehabilitation may have difficulty continuing, especially those with tetraplegia and complete injuries. Females also have more difficulty than males in maintaining compliance with IC procedures.

There is level 4 evidence (from many non-randomized controls) that urethral complications and epididymoorchitis occurs more frequently in those using IC programs for bladder emptying, but the advantages of improved upper tract outcome over those with indwelling catheters outweigh these disadvantages.

There is level 1b evidence (from one RCT; Polliack et al. 2005) that using a portable ultrasound device reduces the frequency and cost of intermittent catheterizations.

There is level 4 evidence (from one case series study; Greenstein et al. 1992) that triggering mechanisms such as the Valsalva or Crede maneuvers may assist some individuals with neurogenic bladder in emptying their bladders without catheterization; however, high intra-vesical voiding pressures can occur which can lead to renal complications.

There is level 4 evidence (from four cases series studies, one observational study, and one pre-post study) that despite an associated significant incidence of urological and renal complications, acute and chronic indwelling catheterization may be a reasonable choice for bladder management for people with poor hand function, lack of caregiver assistance, severe lower limb spasticity, urethral disease, and persistent incontinence with intermittent catheterization.

There is level 4 evidence (from one cohort study; Groah et al. 2002) that those with indwelling catheters are at higher risk for bladder cancer compared to those with non-indwelling catheter management programs.

There is level 4 evidence (from one Newman & Price 1985) that condom drainage may be associated with urinary tract infection and upper tract deterioration.

There is level 4 evidence (from one case series and one pre-post study; Hakenberg et al. 2001; Sylora et al. 1997) that most individuals who receive catheterizable stomas become newly continent and can self-catheterize. It appears possible that this surgical intervention could protect upper tract function. Larger studies are needed to better evaluate true incidence of complications, and long-term bladder and renal outcome.

There is level 4 evidence (from two case series studies; Chartier-Kastler et al. 2002; Kato et al. 2002) that most individuals undergoing cutaneous ileal conduit (ileo-ureterostomy) diversion became newly continent and were more satisfied than with their previous bladder management method. Long-term follow-up demonstrated the presence of a high incidence of urological or renal complications.

There is level 4 evidence (from six pre-post studies, one case series, and one observational study) that ongoing use of sacral anterior root stimulation (accompanied in most cases by posterior sacral rhizotomy) is an effective method of bladder emptying resulting in reduced incontinence for the majority of those implanted. This is associated with increased bladder capacity and reduced post-void residual volume.

There is level 4 evidence (from four pre-post studies and one case series study) that sacral anterior root stimulation (accompanied in most cases by posterior sacral rhizotomy) may be associated with reducing UTIs and autonomic dysreflexia.

There is level 4 evidence (from one pre-post study and one case series study; Madersbacher et al. 1982; Radziszweski et al. 2009) that direct bladder stimulation may result in reduced incontinence, increased bladder capacity and reduced residual volumes (with two year efficacy data from one study group) but requires further study as to its potential for larger scale clinical use.

There is level 4 evidence (from various single studies) that other forms of neuroanatomically-related stimulation (e.g., electrical conditioning stimulation to posterior sacral, pudenal, dorsal penile or clitoral nerve or surface magnetic sacral stimulation) may result in increased bladder capacity but require further study as to their potential clinical use. These non- or minimally invasive techniques are preferred by patients over more invasive methods such as use of the Brindley device, with or without rhizotomy.

There is level 2 evidence (from a one prospective controlled trial; Sievert et al. 2010) that repforts early sacral neuromodulation may improve management of lower urinary tract dysfunction. Further investigation is required to confirm the results and substantiate the hypothesis of resultant plastic changes of the brain.

There is level 4 evidence (from one case series study; Katz et al. 1991) that epidural dorsal spinal cord stimulation at T1 or T11 originally intended for reducing muscle spasticity may have little effect on bladder function.

There is level 4 evidence (from one pre-post study; Wheeler et al. 1986) that a program of functional electrical stimulation exercise involving the quadriceps muscle originally intended for enhancing muscle function and reducing muscle spasticity has only marginal (if any) effects on bladder function.

There is level 4 evidence (from one case series study; Perkash 2007) that sphincterotomy is effective in reducing episodes of autonomic dysreflexia associated with inadequate voiding.

There is level 4 evidence (from one case series study; Pan et al. 2009) that sphincterotomy, as a staged intervention, can provide long-term satisfactory bladder function.

There is level 2 evidence (from a one RCT and several level 4 studies; Chancellor et al. 1999) that both sphincterotomy and implantation of a sphincteric stent are effective in reducing incontinence, with little need for subsequent catheterization, and both treatments are associated with reduced detrusor pressure and reduced post-void residual volume but not with changes in bladder capacity. The only significant difference in these two treatments was the reduced initial hospitalization associated with the stent, given the lesser degree of invasiveness.

There is level 4 evidence (from one pre-post study and one case series study; Chancellor et al. 1993c; Seoane-Rodriguez et al. 2007) that implantation of a sphincteric stent may result in reduced incidence of UTIs and bladder-related autonomic dysreflexia over the short-term although several studies have demonstrated the potential for various complications and subsequent need for re-insertion or another approach over the long-term.

There is level 4 evidence (from one pre-post studroy; Juma et al. 1995) that over the long-term, previous sphincterotomy may contribute to a high incidence of various upper and lower tract urological complications.

There is level 4 evidence (from one case series study; Game et a. 2008) that advocates for placement of a temporary stent early after injury as a reversible option that allows patients to choose from the range of permanent stent placement to less invasive bladder management methods such as intermittent catheterization.

There is level 4 evidence (from one pre-post study; Chancellor et al. 1993b) that transurethral balloon dilation of the external sphincter may permit removal of indwelling catheters in place of condom drainage, and also may result in reduced detrusor pressure and post-void residual volume but not with changes in bladder capacity.

There is level 4 evidence (from one case series study and one pre-post study; Patki et al. 2006Bersch et al. 2009) that implantation of an artificial urinary sphincter may be useful in the treatment of incontinence in SCI but further study is required.

There is level 4 evidence (from one pre-post study; Ke & Kuo 2010) that transurethral incision of the bladder neck may be useful in bladder neck and voiding dysfunction.

There is level 4 evidence (from one case series study; Pannek et al. 2012) that transobturator tape implantation is not effective in managing neurogenic stress incontinence in females living with SCI.

There is level 2 evidence (from one RCT; Cheng et al. 1998) that early treatment with electroacupuncture may shorten the time that it takes to develop low pressure voiding/emptying with minimal residual volume, when combined with conventional methods of bladder management.

There is level 4 evidence (from one pre-post study and one case series study; Zahariou et al. 2007; Chancellor et al. 1994) that intranasal DDVAP may reduce nocturnal urine production with fewer night-time emissions and also may reduce the need for more frequent catheterizations in persons with SCI with neurogenic bladder that is otherwise unresponsive to conventional therapy.

There is level 4 evidence (from one case series study; Escalrin de Ruz et al. 2000) that patients with SCI who are completely dependent (FIM<74) or who have vesicourethral reflux are at highest risk for UTI.

There is level 4 evidence (from one case series study; Massa et al. 2009) that the presence of cloudy urine or a positive urine dipstick test are better predictors of UTI compared with the patient’s own subjective impression of their own signs and symptoms.

There is level 1b evidence (from one RCT; Darouiche et al. 1997) that both limited and full microbial investigation result in adequate clinical response to UTI treatment with antibiotics. Therefore the cost savings attributed to a limited microbial investigation favours this practice in the investigation of UTI although more rigorous investigation of the patient outcomes and attributed costs is needed.

There is level 1a evidence (from one meta-analysis of five RCTs; Li et al. 2013) that the use of hydrophilic catheters versus non-coated catheters is effective in reducing the incidence and occurrence of UTI and hematuria.

There is level 2 evidence (from two RCTs; Moore et al. 2006; Peta-Fingerhut et al. 1997) that there is no difference frequency of UTI between sterile and clean approaches to intermittent catheterization during inpatient rehabilitation; however, using a sterile method is significantly more costly.

There is level 4 evidence (from one prospective controlled trial; Wyndaele & De Taeye 1990) that there is no difference in UTI rates between intermittent catheterization conducted by the patients themselves or by a specialized team during inpatient rehabilitation.

There is level 4 evidence (from one prospective controlled trial; Yadav et al. 1993) that similar rates of UTI may be seen for those using clean intermittent catheterization during inpatient rehabilitation as compared to those using similar technique over a much longer time when living in the community.

There is level 4 evidence (from one pre-post study; Jensen et al. 1995) that differences in residual urine volume ranging from 0-153 ml were not associated with differences in UTI during inpatient rehabilitation.

There is level 2 evidence (from one RCT; De Ridder et al. 2005) that, compared to conventional poly vinyl catheters, hydrophilic catheters may be associated with fewer UTIs, but not necessarily urethral bleeding.

There is level 2 evidence (from two RCTs; Cardenas & Hoffman 2009; Cardenas et al. 2011) that use of hydrophilic versus non-hydrophilic catheters are associated with fewer symptomatic UTIs treated with antibiotics even though the number of symptomatic UTIs are similar between groups.

There is level 2 evidence (from one prospective controlled trial, one case control study, and one case series study; Joshi & Darouiche 1996; Nwadiaro et al. 2007; Afsar et al. 2013) that intermittent catheterization may leadto a lower rate of UTI as compared to other bladder management techniques such as use of indwelling or suprapubic catheter.

There is level 3 evidence (from one case control study; Nwadiaro et al. 2007) that bladder management with a suprapubic as opposed to indwelling catheter may lead to a lower rate of UTI and reduced mortality in a poor, illiterate population where intermittent catheterization may not be viable as an approach to bladder management.

There is level 2 evidence (from one RCT; Darouiche et al. 2006) that use of a Statlocak device to secure indwelling and suprapubic catheters may lead to a lower rate of UTI.g

There is level 2 evidence (from one prospective controlled trial; Gilmore et al. 1992) that removal of external condom drainage collection systems at night or for 24 hours/day might reduce perineal, urethral or rectal bacterial levels but have no effect on bacteriuria.

There is level 4 evidence (from one case series; Ku et al. 2005) that no bladder management method is advantageous in preventing pyelonephritis (though indwelling urethral catheterization does have the highest incidence of upper tract deterioration). However, the presence of reflux results in a 2.8 fold higher incidence of pyelonephritis.

There is level 2 evidence (from one RCT; Cardenas et al. 2004) that a single educational session conducted by SCI specialist health professionals with accompanying written materials and a single follow-up telephone call can result in reduced urine bacterial colony counts in community-dwelling individuals with prior history of SCI.

There is level 2 evidence (from one RCT, and two pre-post study; Hagglund et al. 2005; Barber et al. 1999; Anderson et al. 1983) that there are beneficial effects of education mediated by SCI specialist health professionals on reducing UTI risk in community-dwelling individuals with SCI using various approaches (e.g., one-on-one or group workshops, demonstrations, practice of techniques and written materials).

There is no evidence assessing the relative effectiveness of different educational approaches for reducing UTI risk.

There is level 1b evidence (from one RCT; Dow et al. 2004) that supports the use of 14 versus 3 days of Ciprofloxcin for improved clinical and microbiological outcomes in the treatment of UTI in persons with SCI.

There is level 1b evidence (from one RCT; Reid et al. 2000) that 3 or 7 day Ofloxacin treatment is more effective than trimethoprim-sulfamethoxazole in treating UTI and results in significant bladder bacterial biofilm eradication in persons with SCI patients.

There is level 1b evidence (from one RCT; Sapico et al. 1980) that there is a low success with aminoglycosides for the treatment of UTI post SCI.

There is level 4 evidence (from one pre-post study; Waites et al. 1991) that norfloxacin may be a reasonable treatment for UTI post SCI but subsequent resistance must be monitored.

There is level 4 evidence (from one case series study; Linsenmeyer et al. 1999) that intermittent neomycin/polymyxin bladder irrigation is effective in altering the resistance of the offending bladder organism(s) to allow for appropriate antibiotic treatment.

Optimum antimicrobial treatment duration and dosage is uncertain due to the lack of comparative trials in persons with SCI.